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AP Therapeutic Practice- New Client Information
Please complete the following information. We will verify your insurance benefits and send you an email with your estimated cost of services.
If you have any questions please call 601-207-0774
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* Indicates required question
What type of service are you seeking?
*
Child Therapy (Age 5-12)
Adolescent Therapy (Age 13-17)
Adult Therapy
Couples Therapy
Client's Legal First Name
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Your answer
Client's Legal Last Name
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Your answer
Client's Preferred Name
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Your answer
Client Date of Birth
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MM
/
DD
/
YYYY
Address: Street
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Your answer
Address: City
Your answer
Address: State
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Your answer
Address: Zip Code
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Your answer
If a Minor; Legal Guardians First/Last Name (NA if not applicable)
Your answer
If a Minor; Legal Guardians phone number (NA if not applicable)
Your answer
Client's Phone Number
Your answer
Email Address to put on file (if minor, please provide guardian's email)
*
Your answer
Insurance Company Name
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Your answer
Insurance Member ID #
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Your answer
Insurance Group #
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Your answer
Insurance Company Contact Number (located on the back of the card)
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Your answer
Insurance Subscriber First Name
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Your answer
Insurance Subscriber Last Name
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Your answer
Insurance Subscriber Date of Birth
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MM
/
DD
/
YYYY
Insurance Subscriber Phone Number (used to file claims)
*
Your answer
Insurance Subscriber Address ( If different than the client)
*
Your answer
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